UNIVERSITY OF SANTO TOMAS

THE PONTIFICAL AND ROYAL CATHOLIC UNIVERSITY OF THE

PHILIPPINES
______________________________________

CONSENT FORM

I have read and understood the above information and have been given the opportunity to
consider and ask questions on the information regarding the involvement in this study. I have spoken
directly to the investigators who has/have answered to my satisfaction all my questions. I have received
a copy of this participants information and informed consent form. I hereby voluntarily agree to
participate.

Participant’s Signature

___________________________ ___________________________ ____________

Printed Name of Participant Signature of Participant Date

___________________________ ___________________________ ____________

Printed Name of Legal Guardian Signature of Legal Guardian Date
(Only when participant cannot read or sign this informed consent)

Witness Signature

___________________________ ___________________________ ____________

Printed Name of Participant Signature of Participant Date

Medical Clearance (if needed)

I, the undersigned, certify that to the best of my knowledge, the participant signing this consent
form has read the above information sheet fully, that this has been carefully explained to him/her, and
that he/she clearly understands the nature, risks, and benefits of his/her participation in this study.

Physician’s Signature:

___________________________ ___________________________ _____________

Printed Name of Physician Signature of Physician Date

[N.B. The participants information sheet (pormularyo ng imporasyon) and the consent form (pormularyo ng pahintulot) must be
written and explained in Filipino or any language understood by him/her when needed.]